Full Name *

Phone *

Email *

Do you suffer from any of the following? (select all that apply) *

Trouble falling asleep

Trouble remaining asleep

Excessive sleepiness during the day

Snoring

Unwanted behaviors during sleep, such as sleepwalking, talking or grinding teeth (bruxism)

Narcolepsy

Obstructive Sleep Apnea

On average, how many hours of sleep do you get per night? *

How long does it usually take you to fall asleep? *

How often do you wake up during the night? *

How long do you stay awake when you wake up during the night? *

How often do you feel tired or sleepy during the day ? *

Do you kick or jerk your legs excessively during sleep?

yes

Have you experienced any of the following Parasomnias? (select all that apply) *

Sleepwalking

Sleep Paralysis

Night terrors

Somniloquy (a sleep disorder defined as talking during sleep without being aware of it)

Have you experienced any of the following circadian rhythm sleep disorders? *

Have you ever been diagnosed with depression or anxiety? *

yes

Are you currently taking any medication for the previous diagnosis? *

yes

How often do you snore or experience breathing difficulties during sleep?

Do you engage in any of the following habits or activities that may be affecting your sleep? (select all that apply) such as drinking caffeine or using electronic devices before bed? *

Caffeine

Late night eating

Electronic devices

disruptive bed partner

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.